The arrival next year of the region’s first free-standing emergency room is plunging Concord into the middle of a growing debate in American healthcare: Whether such facilities improve medical access in a community or degrade it, and what they do to patient costs.
John Skevington, CEO of Catholic Medical Center in Manchester, which will run the emergency room at 161 North State Street, says the facility is designed to meet patient needs.
Skevington’s biggest piece of evidence of the need for a Concord facility is wait times at hospital emergency rooms.
NHHealthCost, run by the state Insurance Department, says the median time spent in the emergency department at Concord Hospital before being discharged was 245 minutes, well over the state average of 126 minutes and more than the 216 minutes for Catholic Medical Center. This figure is partly a reflection of the type of patients who seek emergency care, as well as the hospital’s workload, capacity and speed of workup and treatment.
“Wait times in the largest cities in New Hampshire are longer than the national average,” Skevington said. “Free-standing (ERs) bring that care closer to home for patients. … The decision to expand into free-standing ER services is driven by the demand of the patient. We would not continue to build out this network if patients were not responding to it.”
The site, to be called Capital Region ER, will be the fourth free-standing emergency room in New Hampshire. It is slated to open next year on the site of a former Santander bank.
Skevington noted that a free-standing ER has operated in Seabrook, affiliated with Portsmouth Regional Hospital, since 2017: “While it’s a new service for Concord, it’s not new to the state. … It is a proven model in New Hampshire for over 10 years and in many other parts of the country.”
ER vs. urgent care
Catholic Medical Center was purchased at the start of the year by HCA Healthcare, a for-profit healthcare colossus based in Nashville that operates in 20 states and the United Kingdom. Prior to that, the center had been a not-for-profit hospital.
HCA owns 186 hospitals and around 2,400 “ambulatory sites” around the country. The latter include both ERs and acute-care facilities, which sound similar but are very different in service and cost. The company has been aggressively building free-standing ERs in recent years, including one that opened at the former site of Leda Lanes bowling alley in Nashua this year and is also affiliated with Catholic Medical Center.
HCA isn’t alone. Mordor Intelligence estimated that the country’s “free-standing emergency department” market was valued at $15 billion in 2025 and is expected to grow to $20 billion in five years.
Proponents say consolidation allows for greater efficiency and access to advanced health services, but critics say it’s a reflection of industry consolidation and profit-chasing in healthcare that can raise costs while cutting less profitable services like maternity care and behavioral health.
In particular, they say building a free-standing emergency room in a community already served by a non-profit hospital with an ER, such as Concord or Nashua, does two things of concern. First, it draws the most profitable patients away from the non-profit hospital, and it causes patients to pay too much because they don’t realize the difference between urgent care and an emergency room.
“People think it’s a doc-in-a-box, urgent-care type facility … and then get a bill that is at least $500 if not thousands of dollars when they were expecting a co-pay of $50,” said Sam Burgess, director of Healthcare Access and Affordability for New Futures, a Concord-based health advocacy nonprofit.
Urgent care facilities, many of which have sprung up in large numbers over the past decade, are seen as serving a need partway between emergency rooms and the family physician. They are usually open 8 to 12 hours a day, staffed with physicians and nurses but without specialists or much in the way of diagnostic equipment. These sites are also available for minor illnesses or injuries that can’t wait for a doctor’s appointment.
They have long been touted as a way to cut health-care costs by giving people a less-expensive alternative to hospital emergency rooms.
Stand-alone emergency rooms, by contrast, are open 24/7, every day of the year. They have a wide range of specialists on staff and diagnostic equipment available, with connections to all the services of their base hospital. They are designed to be equivalent to an emergency room in a hospital for all traumas and major medical emergencies.
Emergency rooms operate under a host of federal and state rules, especially the Emergency Medical Treatment and Labor Act. For example, they must be within 35 miles of the main hospital, in this case Catholic Medical Center, to be included in that hospital’s Medicare contract for coverage and reimbursement; cannot refuse patients regardless of ability to pay; must have certain levels of staff, and must be open all the time.
Free-standing emergency rooms are expensive to build — usually five to ten times the cost of an urgent care facility — and costly to operate. Catholic Medical Center says the Concord facility will cost $16 million. Covering that cost, especially in a for-profit facility, is the main reason emergency rooms are much more expensive than walk-in clinics even when dealing with the same medical problem.
Confusion between the two types of walk-in medical facilities is common. The city of Concord combines them as “outpatient use” in planning applications, and described the center as an urgent care in its permitting documentation and meetings through September. When the Monitor used the term in recent coverage, readers correctly flagged the distinction. In later city meetings and in application documents, it was made clear that the proposed site is a 24/7 emergency room.
Profit vs. non-profit
For some critics, a major concern of standalone emergency rooms built by a for-profit hospital is what they do to the existing non-profit hospitals, which operate under federal and state rules governing charity care and community health services or benefits.
Skevington of Catholic Medical Center says this is a misplaced concern and that Capital Center ER won’t keep patients from going to Concord Hospital.
Patients who walk into a free-standing E.R. and need to be admitted to a hospital have the right to say where they want to go, he said. They won’t be taken from the Concord clinic to Catholic Medical Center — a distance of about 18 miles compared to the two-mile trip to Concord Hospital — if they don’t want to be.
A bill, HB 1215, passed by the New Hampshire House but stalled in the Senate, would have underlined this point, mandating that people in life-threatening situations go to the nearest hospital and that all others be given an active choice.
Critics say that people in emergency situations aren’t in good shape to make choices like this unless they’ve decided in advance, meaning that free-standing ERs act as a way to expand the patient market for the hospital that owns them, taking away patients and income from the pre-existing hospital.
A study in Texas, where free-standing emergency rooms are common, found that “they are explicitly designed to act as geographic feeders,” said Burgess of New Futures. “Part of the design is to feed patients to a parent facility.”
This is particularly a concern because for-profit hospitals have different priorities than not-for-profits, giving less support to services where all costs aren’t covered by insurance, such as maternity care and behavioral health.
“They are not incentivized to operate services like Concord or Elliot [Hospital] are. If they siphon off traffic that otherwise go to Concord Hospital, in the long run going to hurt the community healthcare,” said Burgess.
Skevington, in response, says only about 5% of patients who come into free-standing emergency clinics are admitted to a hospital. “95% are going home,” he said, meaning the facility has provided treatment that would have required a potentially longer wait at a hospital.
Southern New Hampshire Medical Center in Nashua said it admits “an average of 20%” of emergency room patients “for further treatment or evaluation.” The hospital said the Catholic Medical Center facility in Nashua, opened earlier this year, hasn’t been around long enough to judge what effect it is having on admissions and emergency room visits.
Nashua is unusual in New Hampshire for having two hospitals with emergency rooms near each other. St. Joseph Hospital is a few miles away from Southern New Hampshire, also downtown, while the new Nashua emergency room is a little bit away on busy Route 101A.
Genevieve Armstrong, a spokesperson for Concord Hospital, said in a statement that the hospital couldn’t speculate on what effect the new emergency room would have on them.
“At Concord Hospital Health System, we believe patients are best served when they have access to a coordinated continuum of care, from preventive and primary care services to urgent care, emergency medicine and specialized treatment. As healthcare options continue to evolve throughout New Hampshire, our focus remains on ensuring that emergency services are supported by the broader network of clinical resources patients may need,” the statement says.
Hospital consolidation
To a certain extent, the expansion of free-standing emergency rooms marks a side effect of continuing consolidation in the nation’s healthcare industry.
New Hampshire has 26 acute care hospitals, and only five are stand-alone. The days of a hospital being one building in one town instead of a healthcare network covering a region are fading fast.
HCA owns four hospitals in the state — in Rochester, Portsmouth, Derry and Manchester — while Dartmouth Health owns five. Concord Hospital is relatively independent, though it owns hospitals in Franklin and Laconia as part of its health system.
Larger chains have more access to investment capital that allows them to build facilities and extend their reach — and chains don’t get much larger than HCA.
Given the trends of the past decade, it seems unlikely that consolidation will slow down.
“We are not exclusively focusing on free-standing ER service. We’re investing in all different levels of care,” said Skevington, noting that Catholic Medical Center has an acute care clinic in Bedford. “We plan to continue to invest in that and outpatient services — and demand is going to drive the need. Free-standing emergency rooms is one example of that.”
